December 4, 2022
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Sustainably Growing The Community Doula Workforce In New Jersey

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Pregnant at the beginning of the pandemic, Beatriz von Heydebrand knew that delivery would be hard. Hospitals instituted stricter visitation policies to slow the spread of COVID-19 and Beatriz had no family nearby to help. But she did have a doula:

“My doula was with me during the pregnancy, and she would answer any questions I had. During labor, I just said ‘WOW’ because my doula was there for me for so many hours. Throughout the long, strong pains, she helped me go to the bathroom and gave me food. It was amazing.”

So amazing, in fact, that Beatriz decided to become a community doula as well.

Beatriz’s experience proved that her best support and care came from outside a hospital setting. But many birthing people lack access to high-quality, culturally congruent doula care that can be a crucial part of improving maternal health and a lifeline during trying times. The nation’s maternal health crisis worsened during the pandemic, with deaths up 33.3 percent since March 2020 and racial disparities widening. New Jersey’s disparities are even more stark: Black women are seven times more likely than White women to die from maternity-related complications.

One reason why community doulas are so helpful is that they often share characteristics and experiences with the birthing people they serve. Connecting with patients on the basis of culture, language, race, and ethnicity is vital to providing emotional, physical, and informational support during the prenatal and postpartum periods. Doula care is also associated with such improved outcomes as increased vaginal births, fewer pregnancy complications, and reduced c-section rates. Doulas are also cost-effective, especially for Medicaid clients.

Community Doula Care In New Jersey

To combat racial disparities, promote equitable care, and reduce adverse maternal and infant health outcomes, First Lady of New Jersey Tammy Murphy launched Nurture NJ in 2019. The initiative is grounded in systems-level change to help birthing people thrive in supportive environments. Important steps New Jersey is taking include legislation to reimburse for community doulas services, working collaboratively with doulas to design the Medicaid benefit, and creating the nation’s first Doula Learning Collaborative—a statewide professional association providing training, workforce development, and operational support for doulas and doula organizations.

To support these efforts against the Black maternal mortality crisis, we at the Burke Foundation launched the First 1,000 Days strategy that pairs primary prevention in the earliest years and wraparound services for caregivers with young children. A key pillar is Burke’s work to increase the community doula workforce to 1,000 doulas, who could serve half of the Medicaid births in New Jersey. The Foundation is building on its effort to fund high-quality training and doula services in two maternity-care deserts—Trenton and Paterson. Since 2018, we have provided nearly $752,000 to the Children’s Home Society of New Jersey (CHSofNJ) and the Partnership for Maternal & Child Health of Northern New Jersey.

CHSoNJ’s AMAR (Apoyando Madres/Armando Redes) Community-Based Doula Program, the first one focused on Hispanic women in Trenton, mostly serves recent immigrants, the uninsured, or people on Medicaid who qualify for the Women, Infant, and Children (WIC) program. AMAR so far has trained 23 community members using an evidence-based model developed by HealthConnect One, a national leader in advancing equitable, community-based, peer-to-peer support services. The program has served more than 137 families across Mercer County (mostly in Trenton), and its results are encouraging. Compared to all Medicaid births in Trenton in 2020, women served by AMAR experienced 77.4 percent fewer preterm births, 83.0 percent fewer low birthweight babies, and 52.9 percent fewer low-risk c-sections.

This inspired Burke to co-fund Community of Caring: The Paterson Doula Cooperative, which finished training its first cohort of 13 doulas using the HealthConnect One model in July 2022. The Paterson Doula Cooperative is a joint effort with the Partnership for Maternal and Child Health of Northern New Jersey serving as implementing agency in collaboration with St. Joseph’s Health and the New Destiny Family Success Center. Service will begin in fall 2022.

Challenges For The Trenton And Paterson Doula Pilots

Although the value of community doulas for women of color is clear, the pilots have faced several challenges that threaten the ability of community members to become doulas in these programs.

Hospital Restrictions Can Create Barriers For Patients And Providers

Many hospitals are unaccustomed to doulas working on site and health care providers often don’t understand doulas’ roles. Evidence finds mixed perceptions of doula work amongst hospital‐based maternity care practitioners: Some clinicians appreciate the supportive, patient-centered care that doulas provide, but conflicts can emerge from the cultural divide between obstetric and natural birth cultures and the lack of understanding of the value of community doulas.

Due to the COVID-19 pandemic, Capital Health Medical Center in Trenton didn’t allow doulas to change shifts or leave during long labors for approximately 15 months. However, AMAR worked closely with nurse midwife champion Julie Blumenfeld and hospital administration to define doulas as “shift workers” (similar to nurses and doctors), leading to a reprieve policy for doulas in October 2021. The absence of such a policy can stymie doula care and exacerbate burnout.

Medicaid Can Be Complex

Medicaid billing is designed with a fee-for-service and managed-care option that physicians use with the support of billing specialists. While New Jersey Medicaid prioritizes education and technical assistance to doulas and doula organizations, the procedures and documentation can be challenging for a community workforce with limited Medicaid familiarity. Doulas can find that applications are tedious to fill out, use language and questions that are not relevant to non-clinical providers, and prompt technological issues, leading some doulas to never finish enrollment.

Moreover, relatively low reimbursement rates and limited Medicaid coverage pose barriers to running a high-quality community doula program. In New Jersey, doulas can bill Medicaid up to about $867 (more for a teen client), plus a $100 incentive payment for timely postpartum care. While higher than some states, this is not enough to cover the costs of offering high-quality, patient-centered care that might involve supporting pregnant women over long labors. On top of that, doulas can’t bill Medicaid for serving undocumented families.

Support And Thriving Wages Are Needed To Prevent Burnout

The churn rate for doulas is three to five years, largely due to burnout. Doulas frequently attend births that last for several hours or even days, and community doulas often overextend themselves to help clients lacking other support with such resources as transportation and food. AMAR supervisor Teresita Carrasquillo explains:

“I’ve read that the average duration of the doula career is three years due to burnout or the demands it has in the doulas’ families. Can you imagine for a community-based doula that serves clients that have so many, many needs? It’s very hard.”

While community doulas strive to support their clients, it can be difficult to maintain a healthy balance between work and well-being. Recent doula trainee Angeline Irrizari noted that, as a doula, “you want to give your all. You’re so committed. You have such a passion for it that you neglect yourself.”

The lack of sustainable wages and robust reimbursement rates means that doulas must be entrepreneurial. While several doulas in the Trenton and Paterson programs are full-time employees with benefits (funded through private philanthropy), many across the US work part time and/or get paid a bundled or per visit rate. This could be due to personal preference or because a full-time salary with benefits is not attainable, leaving them to cobble together doula work with other sources of income—a path that may not be viable long term.

Lessons Learned And Recommendations

The Trenton and Paterson community doula pilots provide lessons that will inform future efforts in New Jersey and nationwide:

Streamline Medicaid Enrollment Processes And Increase Reimbursement Rates

Despite its joint federal-state structure with complex regulations, Medicaid has taken proactive steps to facilitate enrollment and equitable compensation for doula services—which other states can consider adopting.

While there are opportunities to further simplify the requirements and procedures, New Jersey listened to doulas and improved the Medicaid enrollment process, allowing doula organizations to contract with the five managed-care plans on their behalf, helping minimize administrative burden. Oregon and Rhode Island are leaders in passing more robust reimbursement packages totaling up to $1,500 per birth, according to the National Health Law program’s tracking of state legislative action.

Adequate compensation recognizes that a doula’s time spent serving clients can vary significantly. States and health insurance plans should also consider conducting time studies to document the services that community doulas provide, as well as the time commitment of each service, to more accurately set reimbursement rates.

Provide Sustainable Wages And Employee Benefits

Medicaid reimbursement for community doula services is crucial to providing culturally congruent care, but sustainable wages are essential to the long-term professional stability of the doula workforce. SisterWeb in San Francisco, California, is one model that assesses the pros and cons of contracted and hourly doula payment models. Recent research finds that doulas who are hourly employees that receive consistent pay, health insurance, and sick leave enjoy greater financial security and well-being. Thus, a sustainable wage and benefits can help to combat burnout by ensuring that doulas are adequately compensated and honored for the physical and emotional labor required in this work and can help minimize any stress associated with economic insecurity.

Clarify Roles And Foster Mutually Respectful Relationships Across Providers

When starting doula pilots, hospital staff at all levels should be involved from the beginning to lay a strong foundation for the doulas. For example, the Partnership for Maternal and Child Health of Northern New Jersey received a commitment from St. Joseph’s University Medical Center in Paterson to deliver educational sessions to clinical staff on the value of doulas and physiologic birth to increase receptivity to including doulas on the maternity care team.

Roger Kierce, MD, chairman of the Department of Obstetrics and Gynecology at St. Joseph’s Medical Center, concludes that:

“Our current practice of delivering maternity care has led to less-than-optimal outcomes. We lack communication, openness, and receptivity to the cultures we interface with. Embracing an organized doula program and welcoming them to our team will do wonders in bridging the gap and restoring the trust and health of our community.”

Next Steps For Doula Expansion In NJ

Burke is partnering with the Greater Newark Health Care Coalition, the Henry and Marilyn Taub Foundation, and to co-design workforce pilots with community doulas to complement local and state efforts to expand and diversify the profession and make it more financially sustainable. The project’s goal is to draw upon the needs, preferences, and lived experiences of doulas to develop a few workforce pilots to test optimal pathways that can support thriving and sustainable careers, such as full-time employment at hospitals, forming cooperative businesses with peers, or credentialing to become lactation consultants. Such initiatives are essential to continue driving meaningful change for the doula profession and making New Jersey a national leader in maternal health care.

Authors’ Note

Special thanks to supervisor Teresita Carrasquillo and community doula Beatriz von Heydebrand (AMAR Community-Based Doula Program, Children’s Home Society of New Jersey) and supervisor Arelis Martinez, community doula Angeline Irrizari, and director of community programs Marie Kinsella (Community of Caring: the Paterson Doula Cooperative, the Partnership for Maternal and Child Health of Northern New Jersey) for participating in interviews for this piece.

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